Mind Your Manners

Beginning January 1, 2009, your on-the-job behavior—and that of other healthcare providers—will be held to a new standard. New Joint Commission standards include a requirement for healthcare organizations to create a code of conduct outlining acceptable and unacceptable behaviors for healthcare professionals, and to implement a process for managing problematic behavior. The reason for this unusual step is the belief that disruptive or intimidating behavior by physicians, nurses, and other healthcare workers has a negative impact on the quality of care.

“I think the standard shows that the Joint Commission is interested in behaviors within hospitals and other healthcare organizations, and how that affects quality of care, safety and the patient experience,” says Russell L. Holman, MD, immediate past president of SHM and chief operating officer for Cogent Healthcare, Nashville, Tenn. “By highlighting this as an area to be included in reviews and standards, it causes organizations to look for their own policies on disruptive behaviors.”

Here is a closer look at the new standard and how it might impact hospital medicine.

Policy Points

Tamper-proof Your Prescriptions

As of October 1, all Medicaid prescriptions that are handwritten or printed from a computer application must contain at least one tamper-resistant feature from each of these three categories: One or more industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription; one or more industry-recognized features designed to prevent the erasure or modification of information written by the prescriber; and one or more industry-recognized features designed to prevent the use of counterfeit prescription.

Prepare for 2009 PQRI

By the time you read this, CMS will have released its 2009 Physician Fee Schedule Final Rule. For the final facts on the Physician Quality Reporting Initiative (PQRI) pay-for-reporting program, visit the CMS Web site at www.cms.hhs.gov/pqri.

Relief from OIG Sanctions

The HHS Office of the Inspector General (OIG) has officially stated an assurance that Medicare providers, practitioners and suppliers affected by retroactive increases in payment rates under the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 will not be subject to OIG administrative sanctions if they waive retroactive beneficiary cost-sharing amounts attributable to those increased payment rates, subject to the conditions noted in the policy statement. Download a pdf of the OIG statement at oig.hhs.gov/fraud/ docs/alertsandbulletins/2008/MIPPA_Policy_ Statement.PDF.

Not Physicians Only

The Joint Commission standard addresses “the problem of behaviors that threaten the performance of the healthcare team,” mentioning unprofessional behavior, specifically “intimidating and disruptive behaviors.” To many, this seems to target physicians. “In a hospital, there is an unwritten hierarchy, with physicians at the top,” Dr. Holman points out. “As such, some feel that different standards are applied to physician behaviors. For example, if a nurse or a pharmacist uses obscene language, they may be terminated. If a physician does this, they may receive feedback that the language was inappropriate.”

However, the Sentinel Event Alert released by the Joint Commission in July states, “While most formal research centers on intimidating and disruptive behaviors among physicians and nurses, there is evidence that these behaviors occur among other healthcare professionals, such as pharmacists, therapists, and support staff, as well as among administrators.” The alert does not single out physicians or any other healthcare profession regarding bad behaviors.

“I think the Joint Commission has been very clear in its intent that the standard applies equally to physicians and non-physicians,” Dr. Holman says.

When Hospitalists Cross the Line

How will this code of conduct standard affect hospitalists? Because of the nature of their work, they will be held to the standards of any hospital they work in. In the case of hospitalists who are directly employed by a hospital, the response should be straightforward. However, independent hospital medicine groups will have to work with their hospitals on behavior issues. First, these groups will need to decide whether they should have their own policies and procedures for code of conduct. “Hospital medicine groups need appropriate systems of identifying disruptive behavior, monitoring it, and taking any necessary actions to make sure the behavior is not continued,” Dr. Holman stresses.

Second, independent groups must communicate closely with the hospital when a behavior issue arises. “If you have a hospitalist who is not directly employed by the hospital, there is a dual responsibility for managing their disruptive behavior,” Dr. Holman says. “The hospital has medical staff standards, which are reflected in the medical staff bylaws and rules and regulations. These documents need to include policy and procedures around the incidence of disruptive physician behavior.”

But just because procedures are in place doesn’t mean the hospital will address a problem hospitalist. “This is where in practice, things can get a little fuzzy,” Dr. Holman admits. “The hospital may defer the responsibility for managing the physician to the employer. This is the scenario that has come up in hospital medicine.” He adds, “In my personal opinion, there is a dual responsibility. The hospital needs to apply its standard to all medical staff, regardless of specialty, tenure or employment status.” At the same time, the hospital medicine group/employer should have—and should implement—an approach to managing disruptive behavior.

“Different employers will have different capabilities,” Dr. Holman says. “For example, large, multi-specialty medical groups may have an infrastructure, including human resources professionals, risk managers and depth of medical and operational management, in place for dealing with disruptive behavior. … Small practices won’t have this. They may rely more heavily on the hospital’s infrastructure.”

The challenge is defining disruptive behavior. A surgeon throwing instruments in the operating room is different than someone who is a little bit outspoken.

—Russell L. Holman, MD, COO, Cogent Healthcare, Nashville, Tenn.

Regardless of the hospital medicine group’s size and capabilities, it should promote two-way communication with the hospital regarding problems with individual hospitalists. “If an incident occurs in the hospital, the employer needs to know the details so they can follow up,” Dr. Holman says. “They have to be careful about sharing appropriate information, and protect all privacies. And they have to balance this communication with the fact that it doesn’t absolve one or the other from acting. There must be follow through from both parties, including disciplinary or corrective action as necessary.”

Defining “Disruptive”

One concern healthcare leaders—and the people they lead—may have is deciding the standard used in crafting a policy that specifies what types of behavior are unprofessional. “The challenge is defining disruptive behavior,” Dr. Holman says. “Of course, it can be very clear sometimes. But a surgeon throwing instruments in the operating room is different than someone who is a little bit outspoken.” Consider a hospitalist or other physician who’s in the habit of questioning authority; could this requirement lead to efforts to shut them down?

“Naturally, there is a degree of concern amongst physicians that this is a physician-directed standard, and that there may be a tough time distinguishing between the good faith criticisms of outspoken physicians and those who demonstrate physically threatening behavior,” Dr. Holman says.

The best way for hospitals, hospital medicine groups and other healthcare organizations to avoid this is to find established policies on this subject that are fair, carefully phrased and comprehensive, then customize one or more to their own specifications and distribute to all affected employees.

“I think these policies are nice to include in new physician orientations or training programs, so that physicians are aware of them,” Dr. Holman suggests.